Basic Information
| Provider Information | |||||||||
| NPI: | 1083154751 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PUEO FAMILY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120A MAKAWAO AVE | ||||||||
| Address2: | |||||||||
| City: | MAKAWAO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967689448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085732222 | ||||||||
| FaxNumber: | 8085732224 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120A MAKAWAO AVE | ||||||||
| Address2: | |||||||||
| City: | MAKAWAO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967689448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8085732222 | ||||||||
| FaxNumber: | 8085732224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2017 | ||||||||
| LastUpdateDate: | 03/01/2017 | ||||||||
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| AuthorizedOfficialLastName: | BEKKUM | ||||||||
| AuthorizedOfficialFirstName: | CURTIS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8085732222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAST MAUI MEDICAL CLINIC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | MD-17180 | HI | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.